NCLEX RN Study Guide 2021 Reliable Guide Graded A, Study notes of Nursing

Download NCLEX RN Study Guide 2021 Reliable Guide Graded A and more Study notes Nursing in PDF only on Docsity! 1 Evaluate Assess Teach Don’t delegate Unstable patients 
 Initial Assessment, Teaching, IV drips, Evaluations only RN AIRBORNE TRANSMISSION-BASED PRECAUTIONS: MTV Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles Private Room: Negative pressure with 6-12 air exchanges/hr Mask: N95 for TB DROPLET TRANSMISSION-BASED PRECAUTIONS: Think of SPIDERMAN! Sepsis Scarlet fever Streptococcal Pharyngitis (Streptococcus group A/ Strep Throat): Can Lead to Glomerulonephritis & Rheumatic Parvovirus B19 Fever. Pneumonia Pertussis Influenza/ Haemophilus influenza type B Diphtheria (Pharyngeal): Serious bacterial infection. Epiglottitis: Medial Emergency! No Throat Inspection. 1 DO NOT DELEGATE WHAT YOU CAN EAT! NCLEX- RN STUDY GUIDE 2 NCLEX RN STUDY GUIDE Rubella/ German measles Mumps Meningitis/ Neisseria Meningitidis Mycoplasma/ Meningeal Pneumonia An - Adenovirus Private Room or Cohort Surgical mask PRN for Procedures Mask 3ft Distance CONTACT PRECAUTION TRANSMISSION-BASED PRECAUTIONS: MRS.WEE Multidrug resistant organism/ MRSA/ VRE Respiratory infection Skin infections Wound infection Enteric infection - Clostridium Difficile Eye infection – Conjunctivitis *MRSA - Contact precaution ONLY. Use Chlorhexidine Wipe! *VRSA - Contact & Airborne precaution (Private room, door closed, negative pressure) *SARS (Severe Acute Resp Syndrome) Airborne & Contact (just like Varicella) SKIN INFECTIONS- VCHIPS- CONTACT Varicella Zoster Cutaneous Diphtheria (Bacteria Infection in the Wound) Herpes Simplex Impetigo (Bacterial Skin Infection) Pediculosis (Lice) Scabies (Itchy Skin condition. Burrowing Trail of the Scabies Mite) 2 5 NCLEX RN STUDY GUIDE PreOxygenated with 100% O2, and Suction should be applied for no more than 10 seconds to prevent hypoxia. The nurse must wait 1-2 minutes between passes to ventilate to prevent hypoxia. Deep reBreathing should be encouraged. The Suction catheter should be No more than half the width of the artificial airway and inserted without suction. Don Sterile gloves if it is not have a closed suction system. Suction should be set at Medium Pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as Excess pressure will traumatize the mucosa and can cause hypoxia. Clients usually Cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, Retracted 1 cm before applying suction. You will ask every New Admission if he has an Advance Directive, and if not you will explain it, and he will have the option to sign or not. Alcohol: a Toxin that causes CNS Depression. Alcohol withdrawal generally starts within 8 hours after the last drink and peaks at 24-72 hours. Acute alcohol intoxication: Confusion, Coordination Impairment, Drowsiness, Slurred Speech, Mood Swings, and Uninhibited actions. Hypoglycemia. Chronic Alcohol Abuse/Alcoholism: Benzodiapepine (lorazepam, diazepam, chlordiazepoxide) – to Treat Gross Tremors, Seizures, Delirium symptom. Chlordiazepoxide: For Alcohol withdrawal. Don’t take with Alcohol (terrible N/V can occur) Thiamine (B1): to treat Wernicke Encephalopathy, a Serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Also can lead to death or neurologic morbidity (Korsakoff Psychosis). Give before or with IV Glucose. Alzheimer’s Disease: Chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of All Dementias. Memantine: Cognition Enhancing medication. It can treat Dementia associated with Alzheimer's disease. Improve symptoms cognition, Daily function, Behavioral problems. 5 6 NCLEX RN STUDY GUIDE Donepezil: Cognition Enhancing medication. Amyotrophic Lateral Sclerosis (ALS): a condition in which there is a Progressive, Degeneration of Motor Neurons in both the Upper & Lower Motor Neuron systems. Upper Motor Neuron issue: Hyper Reflexes Lower Motor Neuron issure: Absent Reflexes S/S: Limb weakness, Dysarthria (difficulty speaking), and Dysphagia. Iron: IM: should be given Z-track so they don't leak into SQ tissues IV: Iron Dextran (Imferon). Can cause hypersensitivity reaction (anaphylaxis), test dose needs to be given First. PO: give with Vitamin C or on an Empty stomach or Btw Meals. Place it on the back of the Month (Stain teeth). Expect Black/Green Tarry Stools. Take iron elixir with juice or water.... Never with milk (Vit D). Iron Poisoning: GI Bleed. Antidote: Deferoxamine Iron Deficiency Anemia: Microcytic anemia. S/S: Fatigue, Pallor, Fissures at the corner of the mouth, Spooning of the fingernail, Reduced exercise tolerance Thalassemia Major (Cooley’s Anemia): Microcytic anemia. S/S: Maxillary Hyperplasia, Frontal Bossing. Caused by: Defects in both Beta-chains of the Hgb molecule. Pernicious Anemia: Macrocytic anemia, Lack of required Intrinsic factor (B12 Deficiency) S/S: Pallor, Tachycardia, Sore Red Tongue (Beefy tongue), Enlarged Liver that can lead to R-sided HF. 6 7 NCLEX RN STUDY GUIDE Take Vit. B12 for life. Shilling Test: Test for Pernicious Anemia. How well one absorbs Vit B12 Folate (Folic Acid) Deficiency: Macrocytic anemia. Risk: Alcoholism or Diet Low in Vegetables. S/S: Stomatitis, Ulcerations on the tongue. Dysphagia, Flatulence, watery Diarrhea Aplastic Anemia: Normocytic Anemia. Decline in blood cell production r/t to Bone Marrow Depression. Can cause an Extremely Low Hgb of 7 g/dL Severe Anemia: (Female hgb 11.7 ~ 15.5) Tachycardia. SOB (Dyspnea). Pallor. (Male hgb 13.2 ~ 17.3) Anorexic: Absence of Menstruation leads to Osteoporosis. Bulimia: Chipmunk Face. Antibiotic: Obtain Cultures before starting IV antibiotics. IV push should go over at least 2 Minutes. Always check for Allergies before Administering (especially PCN). Make sure Culture & Sensitivity has been done before First dose. Give Prophylactic Antibiotic therapy before any Invasive Procedure. Aminoglycocide ( _Mycin e.g. Vancomycin; except Erythromycin): Cause Nephrotoxicity and Ototoxicity. Adverse Effects are Bean Shaped - Nephrotoxic to Kidneys & Ototoxic to Ears Macrolide (Azithromycin, Erythromycin, Clarithromycin): can cause Prolonged QT interval. My lead to Torsade de Pointes (Life-threatening Arrhythmias). 7 10 NCLEX RN STUDY GUIDE Order of Assessment: Inspection, Palpation, Percussion and Auscultation. Except… Abdomen Assessment: Inspect, Auscultate, Percuss then Palpate (Last, bc it may induce pain) Assessment with Kids: Least invasive to Most invasive. An example of when you would Implement Before going through a bunch of Assessments is when someone is experiencing Anaphylaxis. Get the Ordered Epinephrine in them STAT, especially if they clearly States the S/S (Difficulty Breathing, Increasing Anxiety, etc.) Anaphylaxis is a Medical Emergency. Epinephrine Injection is the Only option for treating anaphylaxis. Asthma: Wheezing on Expiration. Coughing Without other s/s is suggestive of asthma. If they stop Wheezing; it could mean it is Worsening. Hyperrsonance: Percussed over Hyperinflated (air) Lung (Asthma, Emphysema). Asthma and Arthritis: Swimming Best Avoid ASA, NSAID (ibuprofen), and Beta Blockers. Asthma has Intercostal Retractions (be Concerned) Exacerbation: Acute, Distress. Wheezing, Dyspnea, Sternal Retraction, Anxiety. Status Asthmaticus: Acute, Prolonged, and Severe Asthmatic Attack that is unresponsive to usual treatment. Hospitalization is usually required. When using a Bronchodilator inhaler in conjunction with a Glucocorticoid inhaler, administer the Bronchodilator First. Theophylline (Bronchodilator): Therapeutic Drug level: 10-20 Tx: of Asthma or COPD Increases the Risk of Digoxin Toxicity, Decreases the effects of Lithium and Phenytoin. Causes GI upset, give with food. 10 11 NCLEX RN STUDY GUIDE Cromoglicic Acid (helps reduce Inflammation): an inhaler used to treat Allergy Induced Asthma. Not for acute asthma attack. Before Pulmonary Function Tests (PFT's): Hold the Bronchodilators. Stop Smoking for 4 hr prior. Incentive Spirometry: 1) Sit upright 2) Exhale 3) Insert mouthpiece 4) Inhale for 3 sec., then Hold for 10 sec. For Prevention of Atelectasis. Atropine: used to Decrease Secretions Atropine Blocks Acetylcholine (remember it reduces secretions). Atropine Overdose: Hot as a Hare (Temp), Mad as a Hatter (LOC), Red as a Beet (Flushed face) and Dry as a Bone (Thirsty) ADHD: Inattention, Hyperactivity, Impulsivity. Methylphenidate/ Ritalin: Assess for Heart related side effects report immediately. May need a Drug Holiday- it Stunts Growth. Dextroamphetamine: may alter Insulin needs, Avoid taking with MAOI's, take in Morning (Insomnia possible side effect) Atomoxetine: Norepinephrine-Specific Reuptake Inhibitor, and can be used for Depression. Autonomic Dysreflexia/Hyperreflexia: Neuro T6 or above. Life-threatening emergency. Uncompensated SNS stimulation (Inhibited Sympathetic Response) Tigger by: Bladder distention and Bowel impaction S/S: pounding/severe HA, profuse Sweating (Diaphoresis), Nasal Congestion, Bradycardia (30~40), Flushing, Piloerection (goose bumps), Nausea, Seizure, Uncontrolled HTN. Can occur weeks to years after the injury. Tx: Place client in sitting position (Elevate Hob) first before any other implementation. 11 12 NCLEX RN STUDY GUIDE High Fowler’s (90o): assist w/ventilation & prevention of HtN Stroke! Loosen constrictive clothing (Decr. skin stimulation) SBP> 300mmHg. Administer antihypertensive meds (may cause stroke, MI, seizure) Most spinal cord injuries are at the Cervical or Lumbar regions. Spinal Shock occurs Immediately after Spinal Injury Halo: remember Safety First; have a Screwdriver nearby. Myelogram: NPO 4-6hr, allergy hx, Phenothiazine, CNS depressants, and Stimulants withheld 48hr prior, table will be moved to various positions during test. Post: Neuro q2-4, Water Soluble HOB Up. Oil Soluble HOB Down (Lie Flat Supine, to prevent HA, and Leaking of CSF) oral analgesics for HA, encourage PO fluids, assess for Distended Bladder, Inspect Site. Benign Prostatic Hyperplasia (BPH): Enlarged Prostate. Reduced size & force of urine. Tamsulosin, Terazosin, Prazosin (Antitensive med): Alpha1 Antagonist: Cause Orthostatic Hypotension & Dizziness. Take it at Bedtime to avoid Syncope and Dizziness or Lightheadedness. Water Intoxication will be Evidenced by Drowsiness and Altered Mental Status in a patient with TURP Syndrome, or as an Adverse Reaction to Desmopressin (for Diabetes Insipidus). Benzodiazepine: Alprazolam/ Xanax Clonazepam/ Klonopin Diazepam/ Distat/ Valium: Status Epilepticus & to treat Anxiety. Lorazepam/ Ativan Midazolam/ Versed: Surgery Zolpidem/ Ambien 12 15 NCLEX RN STUDY GUIDE Each upper ext= 9% Each lower ext= 18% Front trunk= 18% Back trunk= 18% Genitalia= 1% Assess for Smoke Inhalation/ Burns: 1st Degree - Red and Painful 2nd Degree - Blisters 3rd Degree - No Pain because of Blocked and Burned nerves. Tx: High-Flow O2 (100%) to displace CO & Cyanide from hgb. (1st 24 hour): Lactated Ringer’s: 4mL/kg HyperCalcemia: muscle weakness, lack of coordination, abd pain, confusion, absent tendon reflexes, sedative effect on CNS HypoCalcemia: CATS – Convulsions, Arrhythmias, Tetany, Spasms and Stridor. Trousseau’s & Chvostek’s. Ca2+ absorption is impaired when taken in excess of 500 mg per dose. Taken within an hour of meals as food incr. Ca2+ absorption. Constipation is a frequent side effect of Ca2+ supplements. For Chronic Kidney Disease take Ca2+ supplements before meals, to reduce Phosphorus levels Non-dairy sources of Ca2+: Rhubarb, Sardines, Collard Greens. 15 16 NCLEX RN STUDY GUIDE Carbon Monxide (CO): More readily binds to Hemoglobin than O2. Pulse Oximeter: Can’t Differentiate between O2 & CO. CO Poisoning: S/S: HA, Dizziness, Fatigue, Nausea, Dyspnea. Tx: 100% O2. Serum CarboxyHemoglobin Test to Confirm Diagnosis. Normal Value: < 5% Non Smoker. < 10% Smoker. Carbon Dioxide (CO2) Narcosis: High K+ (Expected- Hydrogen floods the cell forcing K+ out). Causes Increased Intracranial Pressure. Cataract: S/S: Painless Vision Loss, Cloudy, Blurry vision, Opacity of the lens. Worst at Night. Tx: Lens Removal Surgery After Cataract Surgery: Sleep on Unaffected side with a Night Shield for 1~4 weeks. Celiac Disease: Barley, Rye, Oats, Wheat. Cephalhematoma (Caput Succinidanium): Resolves on its own in a few days. This is the type of Edema that Crosses the Suture lines. Cerebral Palsy: Poor muscle control due to birth injuries and/or Decrease Oxygen to brain tissues. Head Injury: Elevate HOB 30o to Decr. Intracranial Pressure. No Nasotracheal Suctioning with Head Injury or Skull Fracture. Basilar Skull Fracture: Otorrhea (discharge from the external ear) 16 17 NCLEX RN STUDY GUIDE Orbital Fracture: Battles Sign and Raccoons Eyes Cushing Ulcer: Gastric ulcer associated with IICP. (r/t Brain Injury) Mannitol: Head injury Medication (Osmotic Diuretic): Decr. Cerebral Edema, Decr. ICP, Incr. Urine Output Crystallizes at Room Temp so Always use Filter needle. TIA (Transient Ischemic Attack): Mini Stroke with No Dead Brain Tissue. Short period of cerebral Ischemic. S/S: Brief period of Loss of Vision, Hemiparesis and Slurred Speech. CVA (CerebroVascular Accident): with Dead Brain Tissue. Permanent Deficits. Horner Syndrome. R-CVA: Left-sided hemiplegia, Impulsive, Lack Judgment L-CVA: R-sided hemiplegia, Impairment in Speech and Language. Broca’s area (Frontal): Expressive Aphasia. Wernicke’s area (Parietal/Temporal): Receptive Aphasia. TPA- Aminocaproic Acid Stroke is Not considered Stabilized until approximate 48hr pass without changes. Cerebral Angiogram: Prep: well Hydrated, lie Flat, site Shaved, pulses Marked Post: keep Flat 12-14hr, check Site & Pulses, force Fluids. Subarachnoid Hemorrhage: Emergent, Serious presentation often described as the "Worst Headache of My Life." The onset is usually Abrupt due to rupture of the vessel; High Mortality from recurrent bleeding. 17 20 NCLEX RN STUDY GUIDE Tension Pneumothorax: develops when air enters the pleural space but Cannot escape. Increased intrapleural pressure and excessive accumulation of air can apply pressure to the heart and great vessels and drastically decrease cardiac output. An occlusive dressing taped on 4 sides would prevent the air in the pleural space from escaping on exhalation and would increase the risk for a tension pneumothorax. Tension pneumothorax trachea shifts to Opposite side. Tracheal Deviation: Reduce Cardiac Output & Hypotension. After that get your Chest Tube Tray, Labs, IV. Removal: Take a breath and hold it or Bare down by attempting to Exhale through the mouth and nose with your lips held Closed. Cholecystitis: Limit Fatty foods. Fat stimulates the release of Bile form the Gallbladder. N/V, Restlessness, Diaphoresis. Referred to the R Scapula & Epigastric tenderness. Murphy’s Sign: Pain w/ palpation of Gallbladder (RUQ) area. Cholera: Infection of the small intestine by some strains of bacterium Vibrio Cholerae. Acute Diarrheal Disease; Rice Watery Stool. Chronic Obstructive Pulmonary Disease (COPD): the Baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be Low bc High O2 Conc. blows the patient’s Stimulus for Breathing. 2L Nasal Cannula or less (Hypoxic Not Hypercapnic drive), PaO2 of ~60 Chronic CO2 retainer: SaO2 90% (Normal) CO2 causes Vasoconstriction. Venti Mask for Distress COPD pt. Tiotropium, Ipratropium, Benztropine. Bronchitis: 20 21 NCLEX RN STUDY GUIDE Rhonchi: Continuous, Low-pitched Wheezes usually heard on Expiration that sound like moaning or snoring. The sound originates from air moving through large airways (Bronchi) filled with Mucus Secretions Tx: Medication, Mobilization of secretions. Emphysema: Barrel-Chest. The Stimulus to breathe is Low PO2, Not Increased PCO2 like the rest of us, so don’t slam them with Oxygen. Encourage Pursed-Lip Breathing which Promotes CO2 Elimination. Encourage up to 3000mL/day Fluids, High-Fowlers and Leaning Forward. Cognitive behavioral therapy (CBT): requires that the client learn about the disorder and engage in self- observation and monitoring, relaxation techniques, desensitization activities, and changing negative thoughts. 5 basic components: Education about the client's specific disorder Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, assess the severity Physical control strategies – deep breathing and muscle relaxation exercises Cognitive restructuring – learning new ways to reframe thinking patterns, challenging negative thoughts Behavioral strategies – focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events Cranial Nerves: Sensory=S Motor=M Both=B Oh (Olfactory I) Some Oh (Optic II) Say Oh (Oculomotor III) Marry To (Trochlear IV) Money Touch (Trigeminal V) But And (Abducens VI) My 21 22 NCLEX RN STUDY GUIDE Feel (Facial VII) Brother -Bell’s Palsy A (Auditory VIII) Says Girls (Glossopharyngeal IX) Big -Swallowing & Gag reflex Vagina (Vagus X) Bras - Swallowing & Gag reflex And (Accessory XI) Matter Hymen (Hypoglassal XII) More Assessing Extraocular Eye Movements: Check Cranial Nerves 3, 4, and 6. Cystic Fibrosis: Salty Skin. Fatty Stools. Diet: Low Fat, High Sodium, Fat Soluble Vitamins ADEK. Pancreatic Enzymes are taken with each meal. Respiratory Problems are the Chief concern: Treat with Aerosol Bronchodilators, Mucolytic. Cystitis: Burning on Urination. Frequency, Urgency, Suprapubic Discomfort, Hematuria. CytoMegaloVirus: Ganciclovir: For CMV Retinitis. Pt will need regular Eye exams, report Dizziness, Confusion, or Seizures Immediately. DecortiCate: (Flexor) Toward the 'Cord'. Cortex involvement. Problem with Cervical Spinal Tract or Cerebral Hemisphere. DecerEbrate: (Extensor) The Other way (Out). Cerebellar, Brain Stem involvement. Problem w/in Midbrain or Pons. Weight is the Best indicator of Dehydration. 1kg = 1L 22 25 NCLEX RN STUDY GUIDE Diabetic ketoacidosis (DKA): when body is breaking down fat instead of sugar for energy. Fats leave Ketones (acids) that cause pH to decrease. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. Serum acetone and serum ketones Rise in DKA. As you treat the Acidosis and Dehydration expect the potassium to Drop rapidly, so be ready, with K+ Replacement. While treating DKA, bringing the Glucose Down too far and too fast can result in Increased ICP due to water being pulled into the CSF. Wherever there is Sugar (Glucose) Water Follows. S/S: Kussmauls breathing (Deep Rapid RR), N/V, Abd Pain (Acidic Ketones). Can lead to Death. Fluids are the most important intervention with HHNS as well as DKA, so get Fluids going first. With HHNS there is No Ketosis, and No Acidosis. Potassium is Low in HHNS (due to Diuresis). Second Voided Urine most accurate when testing for Ketones and Glucose. Oral Hypoglycemic: Typical Adverse reaction: Rash, Photosensitivity Extra Insulin may be needed for a patient taking Prednisone (Steroids cause Increased Glucose). Diabetes Insipidus (decreased ADH): Thirst, Dehydration, Weakness, Excessive Urine Output (Diluted Urine) Administer Pitressin SIADH (increased ADH): Change in LOC, Decr. deep tendon reflexes, Tachycardia, n/v, HA, No Urine Output (Conc. Urine). HypoNa+, HypoCa2+. 25 26 NCLEX RN STUDY GUIDE Administer Declomycin, Diuretics Hemodialysis (HD): Solutes (e.g. Urea) are removed from the blood. Complication: Dialysis Disequilibrium Syndrome (DDS) Allen’s Test: occlude both Ulnar and Radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar artery is good and you can carry on with ABG/radial stick as planned. (To check for sufficient blood flow) ABG: must be put on Ice and Whisked to the lab. When drawing an ABG, you need to put the blood in a Heparinized tube, make sure there are no bubbles, put on ice immediately after drawing, with a label indicating if the pt was on room air or how many liters of O2. Peritoneal Dialysis (Cath Tenckhoff): Normal to have Abdominal Crap, Blood tinged outflow and Leaking around site if it was placed in the last 1-2 wks. When Outflow is Inadequate: Turn pt from Side to Side before checking for kinks in tubing. Monitor for Resp. Distress (e.g. Crackles) Cloudy outflow (Infection) Dialysis Disequilibrium Syndrome (DDS): Life-Threatening! Solutes (e.g. Urea) are removed more quickly from the blood than from the brain cells and Cerebrospinal fluid, creating a Concentration gradient that can lead to Excess Fluid in the brain cells and Increased Intracranial Pressure (IICP). Characteristic Neurologic manifestations include n/v, ha, restlessness, change in mentation, seizure, and Pupillary changes. Can be prevented by Slow/Stop the Rate of dialysis. Can progress to Coma and Death. Tx: Decrease Cerebral Edema and manage symptoms. HCP should be contacted Immediately. 26 27 NCLEX RN STUDY GUIDE Diaphragm must stay in place 6 hours After intercourse. They are also fitted so must be refitted if you Lose or Gain a significant amount of Weight. Acid Ash Diet: Bread, Cheese, Corn, Cranberries, Meat, Poultry, Plums, Prunes, Pastry. Alk Ash Diet: Milk, Rhubarb, Salmon, Vegetables. Diphtheria: Pseudomembrane formation. Serious bacterial infection that can cause Organ Damage and Breathing problems. Disseminated Herpes Zoster: Airborne Precaution Localized Herpes Zoster: Contact Precaution A nurse with a Localized herpes zoster can care for patients as long as the Patients are Not Immunosuppressed and the lesions must be Covered. Diverticulitis: Inflammation of the Diverticulum in the Colon. Often in the Sigmoid Colon. Pain is around LL quadrant. Low Residue (Low Fiber), No Seeds, Nuts, Peas. Complication: Peritonitis (LUQ Pain). Down Syndrome: Protruding Tongue. Floppy muscle tone. To Prevent Dumping Syndrome (Post-Operative ulcer/stomach surgeries): eat in Low-Fowler’s during meals, lie Down after meals for 20-30 minutes (Decrease Peristalsis), Restrict Fluids during meals (wait 1hr), Low CHO and Fiber diet, Incr. Fat and Protein, Small frequent meals, Eat slowly. S/S: Dizziness, Hypotension, Syncope, Generalized Sweating, Tachycardia, Palpitation, n/v, Diarrhea, Abd pain. Gastrojejunostomy (Roux-En-Y Surgery): Risk for Dumping Syndrome. Iron Deficiency Anemia. Cobalamin Deficiency. 27 30 NCLEX RN STUDY GUIDE Aim the Nozzle Squeeze the Handle Sweep back and forth over the fire. Fractured Hip: S/S: External Rotation, Shortening, Adduction. Fat Embolism: Blood tinged sputum (r/t Inflammation), Incr. ESR, Respiratory Alkalosis (Not Acidosis r/t Tachypnea), Resp. Distress, Altered Mental Status, Hypocalcemia, Incr. serum Lipids, "Snow Storm" Effect on CXR. Petechiae (Treated w/ Heparin) in the chest, axillae, soft palate. Heparin Prevents Platelet Aggregation. No ASA & NSAID. Monitor PTT. Antidote: Protamine sulfate Reduce the Risk: Minimizing the move of a fractured long bone &early stabilization of the injury w/ surgery. Tx? Greenstick Fractures: usually seen in Kids bone breaks on one side and bends on the other Compartment Syndrome: an Emergency situation. Paresthesia and Incr. Pain are classic symptoms. Neuromuscular Damage is Irreversible 4-6 hours After onset. Cast: Petal the rough edges of a plaster cast with tape to avoid skin irritation. Itching under cast area- cool air via blow dryer, ice pack for 10- 15 minutes. Never use anything to scratch area Place Wheelchair Parallel to the bed on the side of Weakness. “Step Up” when picturing a person going Up Stairs with crutches. The Good leg goes Up first, followed by the crutches and the bad leg. The opposite happens going Down. The Crutches go first, followed by the good leg. COAL (Cane Walking) Cane Opposite Affected Leg 30 31 NCLEX RN STUDY GUIDE 4 Point Gait: Move the Right crutch forward. Move the Left foot forward. Move the Left crutch forward. Move the Right foot forward. GastroEnteritis (Stomach Flu): Trimethobenzaminde: Tx for Nausea associated with Gastroenteritis (Stomach Flu) and PostOp n/v GastroEsophageal Reflux Disease (GERD): Barrett’s Esophagus (Erosion of the Lower portion of the Esophageal Mucosa) Patients should lay on their Left side with the HOB elevated 30 degrees. Weight Loss. Small Frequent Meals Nonfat milk Reduces reflux by Incr. Lower Esophageal Sphincter Pressure. No Carbonated drink (Incr. Pressure). Peptic Ulcers (Coffee-Brown Emesis) caused by H. Pylori (duodenal ulcer) are treated with Metronidazole (can cause dark-urine [Expected]), Clarithromycin, and Omeprazole. This Treatment Kills bacteria and Stops production of stomach acid, but does Not heal ulcer. Cause: NSAID (Celecoxib, Naproxen) Gastric Ulcer Pain: occurs 30 minutes to 90 minutes after eating, not at night, and doesn't go away with food. Pantoprazole/ Protonix (PPI): given Prophylactically to Prevent Stress Ulcers. Omeprazole (PPI): Take it Before breakfast (72 hour duration) Combined with Warfarin (Take it at Evening), Can Incr. INR. Metoclopramide/ Reglan (Antiemetic): prescribed for the GERD. Decr. Post-up Nausea by Promoting Gastric Emptying. Common Side Effects: Sedation, Fatigue, Restlessness, HA, Sleeplessness, Dry mouth, Constipation, Diarrhea Extrapyramidal adverse effects, including tardive dyskinesia (TD), especially in older adults w/ long-term use. 31 32 NCLEX RN STUDY GUIDE TD Symptoms: Call HCP if develops. Protruding and twisting of the tongue Lip smacking Puffing of cheeks Chewing movements Frowning or blinking of eyes Twisting fingers Twisted or rotated neck (torticollis) Cimetidine (H2 antagonist): Antacid and Antihistamine. Take with Food. Caution with Elders. Interacts with a lot of things. Aluminum Hydroxide/ Amphojel: Antacid and Phosphate Binders. Tx of GERD and Kidney Stones. Risk for Constipation. Long term use leads to Weaker Bones (Decr. Phosphates, Incr. Ca2+ (from the Bones). Sevelamer HCl (Phosphate Binder): Take with food. Sucralfate (Antacid): Risk for Constipation. Tx of Duodenal Ulcers. Coats the ulcer/Mucosal Barrier (take one hour Before meals to Coat the stomach). Create Viscous Substance Forms a Protective Barrier. Misoprostol: Prevent Stomach Ulcers caused by NSAIDs. Give Antacid to a Mechanically Ventilated patient w/ NG tube if the pH of the Aspirate is < 5.0, Checked at least every 12 hrs. Glasgow Coma Scale Eye opening
 (Maximum = 4) 4 - Spontaneous (open with blinking at baseline) 3 - To speech 2 - To pain only 1 - None 32 35 NCLEX RN STUDY GUIDE If the current level of paralysis is at the Knees and is therefore not the priority as it has not yet reached the Diaphragm. Keep eye on Respiratory System (absence of reflexes). Muscle weakness can lead to Resp. muscle paralysis, patient Unable to Cough effectively (Risk for Aspiration). Risk for Neuromuscular Respiratory Failure. Heart Failure: Anytime you see Fluid Retention. Think Heart problems first. Adding K+ to a diet, especially when substituting it for sodium, can Decrease BP and fluid retention. Avoid Sodium. S3 sound is Normal in CHF, not in MI. Fluid Volume Overload caused by IVC fluids infusing too quickly (or whatever reason) Nitroprusside (vasodilator): monitor Thiocyanate (Cyanide). Normal value should be 1. Greater than 1 is heading toward Toxicity ACE Inhibitor: Med of choice for CHF. Furosemide: May Cause Low K+, can Cause Anorexia due to Reduced K+. Give it slowly to prevent Ototoxicity, when giving more than 120mg. Digoxin (Cardiac Glycoside): check Pulse, Hold if hr < 60, (Children: Hold if hr <100). Check Dig levels (0.5-2.0) and K+ levels. Patient on Dig and Furosemide: Low K+ Potentiates Dig and can Cause Dysrhythmias. Digitalis Increases Ventricular Irritability, and could Convert a rhythm to V-Fib following Cardioversion. You better pick ‘Do Vitals’ Before administering that Dig. (Apical pulse for One full minute). Avoid salt substitutes when taken Dig and K-Supplements because many are Potassium based Antidote: Digoxin immune fab. Right-Sided HF: Systemic Venous Congestion. Cor Pulmonale (Fluid Overload): caused by Pulmonary disease (Bronchitis/ Emphysema) Juglar Venous Distension: Elevated Central Venous Pressure (CVP) 35 36 NCLEX RN STUDY GUIDE Hepatomegaly Splenomegaly Ascites Edema: related to Sodium and Fluid Retention Left-Sided HF: Pulmonary Congestion. Cardiomegaly: Displaced PMI, S3 sound Pulmonary Edema: Dyspnea, Orthopnea, Crackles B-type Natriuretic Peptides (BNP): peptide that causes Natriuresis. Made, stored, and released primarily by the Ventricles. They are produced in response to Stretching of the Ventricles (blood volume and higher levels of extracellular fluid (Fluid Overload)). Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. Acute Decompensated Heart Failure (ADHF): marginally Low BP, Crackles in the Lungs, Low O2 saturation, Jugular Venous Distension (JVD), and Peripheral Edema. Beta blockers (LOL) can Cause the client to further Deteriorate. It can Worsen heart failure symptoms by Decr. normal compensatory Sympathetic Nervous System responses and Myocardial Contractility. It is a Potentially Fatal Cause of Acute Respiratory Distress. Tx: Sit Upright (to clear the lungs, facilitate O2), Administer Dobutamine, Furosemide, Reduce Stress. Pt w/ Heat Stroke: lie Flat w/ Legs Elevated Hemophilia: X-linked. Mother passes disease to Son. Hemophilia A: deficiency of Factor VIII (8) Hemophilia B: deficiency of Factor IX (9) Hemophilia C: deficiency of Factor XI (11) 36 37 NCLEX RN STUDY GUIDE Von Willebrand Disease: Deficiency of Von Willebrand Factor. (vWf helps release factor VIII), Prolonged aPTT and Decr. Platelet adhesion. Risk for Bleeding. Hepatitis: Hep A: ends in a VOWEL, comes from the BOWEL (Contact Precautions). Fecal-oral route. It is often spread by Contaminated Food. During the Acute stage of Hep A, Gown and Gloves are required. In the Convalescent stage it is no longer contagious. S/S: Anorexia, N/V, Weakness, Fatigue, Clay colored BM, Dark/Brown urine, Low-grade Fever, Jaundice. Hep B: Blood and Bodily fluids (Standard Precautions) Hep: C is just like B Hodgkin’s Lymphoma (HL): Cancer of lymph is very Curable in early stage. Painless, Progressive Enlargement of Spleen & Lymph tissues, Reed-Stenberg Cells. Huntington's Disease (Chorea): 50% Genetic, Autosomal Dominant Disorder. S/S: Writhing, Twisting, Movements of Face, Limbs and Body. Gait Deteriorates to No ambulation No Cure, just Palliative Care. Iatrogenic: means it was Caused by Treatment, Procedure, or Medication. Increased ICP: BP (Hypertension), Pulse (Bradycardia), Resp.(Bradypnea) LOC is Priority (think ICP or Hemorrhage). Slowed Cheyne-Stokes (Irregular) Resp. Cushing's Triad: Systolic Hypertension with Widened Pulse Pressure, Bradycardia, Resp. Depression 37 40 NCLEX RN STUDY GUIDE Liver Cirrhosis: Spider Angiomas (eg, small, dilated blood vessels with bright red centers), Gynecomastia, Testicular atrophy, and Palmar erythema are Expected findings in cirrhosis due to altered metabolism of hormone in the liver. Jaundice. Esophageal Varices. Itching (Can give Cholestyramine). Decr. Protein & Decr. Albumin. Albumin: (3.5 ~ 5g/dL) Low Level. Pitting Edema. Periorbital Edema. Ascites. Sengstaken-Blakemore Tube used for Tx of Esophageal Varices (to Stop Bleeding), Keep Scissors at bedside. A patient w/ liver cirrhosis and edema May Ambulate, then sit with Legs Elevated to try to mobilize the edema. Ascites: Portal Hypertension & Hypoalbuminemia. Paracentesis: Semi-Fowlers or Upright on Edge of bed, Empty Bladder. Post: VS, report Elevated Temp, Observe for signs of Hypovolemia. Hepatic Encephalopathy (HE): frequent Complication of Liver Cirrhosis. It results from accumulation of ammonia (Elevated Ammonia levels) and other toxic substances in blood. 2~3 BM ok. Precipitating factors: Hypokalemia, Constipation, Gastrointestinal Hemorrhage, and Infection. S/S: Sleep disturbances (Early) to lethargy and coma. Mental status is altered. Asterixis (Flapping Tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Fetor Hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. Monitor for Dehydration, Incr. Na+, Decr. K+. Antidote Ammonia: Lactulose. Prior to Liver Biopsy: Important to be aware of the lab result for Prothrombin Time (9~12sec) Administer Vit K+, NPO Morning of exam 6hr, give Sedative. During: Hold breath for 5-10 sec, Supine position, Lateral with Upper arms Elevated. Post- Position: Lay on Right side, Frequent VS, Report Severe abd Pain STAT, No Heavy lifting 1 week. 40 41 NCLEX RN STUDY GUIDE Lyme Disease: found mostly in Connecticut. S/S: Bull’s Eye Rash (Circular outwardly expanding Rash). Tx: Doxycycline (abx) Macular Degeneration: (Age Related) Progressive, Incurable disease of the eye in which the Central Portion of the Retina, the macula, begins to deteriorate with Age. S/S: Distortion (Blurred or Wavy disturbances) or Loss of the Central field of Vision; the Peripheral vision remains Intact. "Dry" Macular Degeneration: occurs when the microvasculature supplying the macula is Blocked, causing Ischemia. "Wet" Macular Degeneration: Abnormal blood vessels form and eventually Destroy the macula. Magnetic Resonance Imaging (MRI): Claustrophobia, No Metal, assess Pacemaker. Malaria: Step Ladder like Fever with Chills. Koplick's Spots are red spots with blue center characteristic of Prodromal stage of Measles. Usually in mouth. Complications of Mechanical Ventilation: Pneumothorax, Ulcers. Meniere's Disease: Administer Diuretics to Decr. Endolymph in the Cochlea, Restrict Na+, lay on Affected ear Triad: N/V, Tinnitus (Excess fluid inside the inner ear), Vertigo. Drop attacks. Aural Fullness. Fall Precaution. Salt Restriction. Meningitis: CSF- High Protein, Low Glucose. Nuchal Rigidity, Photophobia. Kernig’s Sign: Leg flex then leg Pain on extension. Brudzinski Sign: Neck flex; Lower Leg flex. 41 42 NCLEX RN STUDY GUIDE Lumbar Puncture: pt is Positioned in Lateral Recumbent Fetal position. Post: Lay Flat Supine (4~12 hrs as prescribed), to prevent HA and Leaking of CSF. Sterile Dressing Applied, Frequent Neuro Assessments (q15-30 until stable). Encourage Fluids. Metabolic Acidosis: Diarrhea (Poo Bases) Metabolic Alkalosis: Vomitus (Throwing up Acids) Respiratory Acidosis: Respiratory Alkalosis: Hyperventilation (Blowing off CO2) In pH Regulation the Two Organs of concern are Lungs/Kidneys. Methicillin-Resistant Staphylococcus Aurea (MRSA): use Chlorhexidine wipes. 1.3- 2.1 mEq/L HyperMg: Depress CNS, Hypotension, Facial flushing, Muscle weakness, Absent deep tendon reflexes, Shallow respirations, Emergency (Can result in Cardiac Arrest!) HypoMg: Tremors, Tetany, Seizures, Depression, Confusion, Dysphagia; Dig Toxicity, Dysrhythmias (Torsades de Pointes) Multiple Myeloma (Blood Cancer): Bence-Jones Protein in the Urine Diagnose & Confirms. Forms from WBC (Plasma Cell) Malignant. Multiple Sclerosis: Chronic, Progressive disease with demyelinating lesions in the CNS which affect the White matter of the brain and spinal cord. Myelin Sheath Destruction, Disruption in nerve impulse conduction. S/S: Charcot’s Triad (NIS): Nystagmus, Intention tremor, Scanning or staccato speech. Bowel and/or Bladder Incontinence or Retention Hyperactive deep tendon reflexes, Vision changes, Fatigue and Spasticity. 42 45 NCLEX RN STUDY GUIDE Soft bristled toothbrush, No insertion of anything (Suppositories, Douche), No IM meds as much as possible. Nitroglycerine: is administered up to 3 times (every 5 minutes). If chest pain does not stop go to hospital. Do Not give when BP is < 90/60. NSAID: Decr. the effectiveness of Diuretic and Blood Pressure medications. Long-term use is also associated with Chronic Kidney disease and Peptic Ulcers. Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. Kidney injury - long-term use is associated with kidney injury Hypertension and heart failure - can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension Indomethacine: Tx of Arthritis (Osteo, Rhematoid, Gout), Bursitis, and Tendonitis. Use Cold for Acute pain (eg. Sprain ankle) and Heat for Chronic (Rheumatoid Arthritis) Guided imagery is great for Chronic Pain. When patient is in Distress, medication administration is Rarely a good choice. Statin (Anticholesterol med): must be given with Evening meal (most cholesterol is Synthesized by the Liver during the fasting state, at night). Contraindicated severe Liver or Muscle injury. Simvastatin, for hyperlipidemia, take on Empty stomach to enhance absorption, report any unexplained muscle pain, especially if fever. Ezetimibe: Inhibits the intestinal absorption of Cholesterol and is often Combined with a Statin to treat hyperlipidemia. After Myringotomy (Ear Tube): position on side of Affected Ear after surgery (allows drainage of secretions). 45 46 NCLEX RN STUDY GUIDE Nasogastric (NG) Tube: connect the main lumen of the NG tube (using an adaptor) to the suction apparatus and leave the blue pigtail lumen Open to air to facilitate gastrointestinal decompression. Regular flushing of the NG tube with water prevents clogging and allows the suction apparatus a clear pathway to decompress the suction. An NG tube can be Irrigated with Cola, and should be taught to family when a client is going Home with an NG tube. Flush and Aspirate the tube w/ Warm water. Then try it w/ Digestive Enzyme Solution. Weighted Nasointestinal Tube: must float From Stomach to Intestine. Don't tape the tube right away after placement, may leave coiled next to pt on HOB. Position patient on Right to facilitate movement through Pylorus. After G-Tube placement: the Stomach contents are Drained by Gravity for 24 hours Before it can be used for feedings. HyperNatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia, hypotonic solution Skin flushed Agitation Low grade fever Thirst Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids NephrOtic Syndrome: is caused by glomerular damage, which allows the Leakage of Proteins into urine. S/S: Generalized edema, Weight gain (fluid overload), Hypotension, massive Proteinuria (urine looks dark and frothy), Hyperlipidemia, Albuminuria, Hypoalbuminemia. 46 47 NCLEX RN STUDY GUIDE WBC shift to the left in a patient with Pyelonephritis (Neutrophils kick in to fight infection) Turn and Reposition (risk for impaired skin integrity) Tx: Corticosteroids (In general are started at High Dose & Slowly Tapered to Reduce the Risk of Sudden Adrenal Crisis. Glomerulonephritis: take VS q 4hr and daily weights. Consider BP to be your most important assessment parameter. Dietary Restrictions: Fluids, Protein, Na+, K+. Gross Hematuria (Expected) IVP: requires Bowel Prep so they can Visualize the Bladder better. A Laxative is given the night before in order to better visualize the organs. Acute Glomerulonephritis (AGN): Caused by: Strep throat, Impetigo (bacterial infection of the skin caused by Streptococcal Pyogenes) with a latent period of 10 ~ 14 days in between. Pyelonephritis: Inflammation of the Kidneys. S/S: N/V, Fever & Chills, Flank Pain, Costovertebral Tenderness. Pyelogram: Assess Allergies. Renal Crisis: Life-Threatening. Malignance HTN Leads to Kidney/ Organ Failure. Renal Impairment: serum Creatinine Elevated and Urine Clearance Decreased Norm. Serum Creatinine: 0.8-1.8 (men), 0.5-1.5 (women) Norm. Urine Clearance: 85-135 Low Mg2+ and High Creatinine- Signal Renal Failure. Kidney Glucose Threshold is 180 Uremic Fetor: smell Urine on the breath (CKD). 47 50 NCLEX RN STUDY GUIDE Benztropine Injection: Extrapyramidal effects of other drugs. Ropinirole, Pramipexole: Sleep attacks, Extreme Drowsiness. Pemphigus Vulgaris (Autoimmune): Painful Blistering on the Skin and Mucous Membranes. Nikolsky’s Sign: Separation of epidermis caused by rubbing of the skin. (Blister) Pericarditis: Inflammation of Visceral and/or Parietal Pericardium. Cardiac Output is Diminished. S/S: Pericardial Friction Rub, Pleuritic Chest Pain (Sharp), Aggravated during Inspiration & Coughing, Fever, Leukocytosis, ST-segment Elevation. Lean Forward: will pull the heart Away from the lungs, Preventing Pericardial Irritation caused by friction and contact with the lungs. Tx: NSAID/ ASA & Colchicine (Gout med). Pericardiocentesis: a procedure where fluid is Aspirated from the Pericardium. Positioned the pt Supine with the HOB 30O ~ 60O. Complication: Cardiac Tamponade (Paradoxical Pulse). Cardiac Tamponade: (Beck’s Triad) Hypotension, Muffled Heart Sounds, Distended Neck Veins. Paradoxical Pulse: Stroke Volume or Sbp > 10mmHg during Inspiration. PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated) EleVate Veins; dAngle Arteries for better perfusion. Pheochromocytoma (PCC) (Benign Tumor on the Adrenal Gland/Medulla): Hypersecretion of Epi/Norepi, persistent HTN, Tachycardia, Palpitations, Hyperglycemia, Diaphoresis, Tremor, Pounding HA; Stress, Frequent rest breaks, Avoid Cold and Stimulating foods. Weight loss Tx: Surgery to remove Tumor 50 51 NCLEX RN STUDY GUIDE Adrenal Medulla: Secrete Catecholamine (Epinephrine and Norepinephrine) and Dopamine. Adrenal Cortex: Secrete Glucocorticoids (Cortisol), Mineralocorticoids (Aldosterone), Androgens (Testosterone) Anterior Pituitary Gland: Prolactin, Growth Hormone, ACTH, Follicle-Stimulating Hormone (TSH), Thyroid-Stimulating Hormone (TSH), Luteinising Hormone (LH), Melanocyte-Stimulating Hormone (MSH). Posterior Pituitary Gland: ADH and Oxytocin. Removal of Pituitary Gland, watch for Hypocortisolim and Temporary Diabetes Inspidus. Polycythemia: Elevated Hgb levels and Hct levels. Compensatory mechanism due to prolonged tissue hypoxia. Increase Blood Viscosity (risk for stroke or thromboembolism). Tx: Hydration. Polycythemia Vera (PV): Slow growing Blood Cancer. Chronic Myeloproliferative Disorder. Incr. RBC. Risk of Blood Clots (Heart Attack or Stroke). Periodic Phlebotomy: 300~500mL. Postoperative Cognitive Dysfunction (POCD): Memory Impairment & Problems with Conc., Language Comprehensive social integration and emotional ability after Major Surgery. Symptoms typically resolve after 4-6 weeks or when healing is complete. No Pee, No K+ (do not give Potassium without adequate Urine Output). Take it with Food. Never give K+ in IV Push. 51 52 NCLEX RN STUDY GUIDE Low Potassium Potentiates Dig Toxicity. If every answer in front of you is an Abnormal value. If Potassium is there you can bet it is a problem they want you to identify, because values outside of normal can be Life-Threatening. Even a bun of 50 doesn’t override a Potassium of 3.0 in a renal patient in priority. Hyperkalemia: (MURDER) – Muscle weakness, Urine (oliguria/anuria), Respiratory depression, Decr. cardiac contractility, ECG changes, Reflexes. Bradycardia, Diarrhea, Nausea. Check Pulse first: Due to Dysrhythmias May be Due to Inability of the Adrenal Gland to Secrete Aldosterone (K+-Wasting Hormone) Kayexalate (Na+ Polystyrene Sulfonate): Need to worry about Dehydration (K+ has Inverse Relationship with Na+) Don't use Kayexalate if patient has Hypoactive Bowel Sounds. Hypokalemia: Muscle weakness, Dysrhythmias. K+ Containing Food: Apricots, Bananas, Beans, Carrots, Celery, Citrus fruits, Oranges, Potatoes, Raisins. Use ABC’s & Maslow for Priority Need Bleeding is part of the ‘Circulation’ assessment of the ABCD’s in an Emergent Situation. Therefore, if Airway and Breathing are accounted for, a compound fracture requires assessment before Glasgow coma scale and a neuro check (D=disability, or Neuro check) Priapism: Painful Erection lasting longer than 6 hrs. 52 55 NCLEX RN STUDY GUIDE " Atelectasis (Diminished Lung Sounds): Common Complication after Heart Surgery. Encourage Deep Breathing. Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in clients who have undergone abdominal surgery due to shallow breathing related to pain. Although the presence of fine crackles requires treatment (eg, ambulation, deep breathing). Fremitus: Palpable vibration felt on the chest wall. Sound travels faster in solids (Consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. The presence of egophony, bronchophony, or whispered pectoriloquy also suggests a consolidative process. Fluid or air outside the lung interrupts the transmission of sound, resulting in decreased fremitus in Pleural effusion and Pneumothorax. Hemothorax: Collection of Blood in the Pleural Space. Risk of Empyema. Empyema: Infected pocket of Fluid (Pus) in the Pleural Space. Nonproductive cough. 55 56 NCLEX RN STUDY GUIDE Pleural Effusion is collection of fluid (>15-20 mL) in the pleural space between the parietal and visceral pleurae that prevents the lung from expanding fully; the lung under is compressed. This results in Decreased lung volume, Atelectasis, and Ineffective gas exchange. S/S: Dyspnea on exertion, Non-productive Cough, Diminished/Absent Breath sounds, Dullness to percussion, Decr. Tactile Fremitus. Trachea (mediastinum) deviated (if the effusion is large). Tx: Diuretics or Thoracentesis. Thoracentesis Prep: Take VS, Shave area around needle insertion, Position patient with arms on pillow on over bed table or lying on side, No more than 1000mL at a one time. Post: Listen for Bilateral Breath Sounds, Check Leakage, Sterile dressing, VS. Diminished BS, Retractions, Dyspnea, Incr. RR, Cyanosis Could be Pneumothorax. Pneumonia: Acute condition. S/S: Fever and Chills. Rusty Sputum. Complication: Pleurisy (S/S: Pleuritic Pain, Stabbing Pain, Inflamed Parietal and Visceral Pleurae Rubbing together). Crackles: suggest Pneumonia, which is likely to be accompanied by Hypoxia, which would manifest itself as mental confusion, etc. Can’t Cough: Ineffective Airway Clearance Positioning: Lay On (Down) the Affected Side to Splint and Reduce Pain (Pleuritic Pain: Inflammation of the two layers of pleura). Reduce Congestion the Sick lung goes Up. For the Elderly: Confusion is often present. Pulmonary/Air Embolism: S/S: Chest Pain, Difficulty Breathing, Tachycardia, Pale/Cyanotic, Sense of Impending Doom Position: Turn pt to Left side & Lower the HOB. Trendelenburg. When O2 Deprived: the Body Compensates by causing Hyperventilation (Resp. Alkalosis). Should the patient breathe into a paper bag? No. If the Pa O2 is well below 80 they need O2. 56 57 NCLEX RN STUDY GUIDE Look at all your ABG values. As soon as you see the words PE you should think Oxygen First. First Sign of PE: is Sudden Chest Pain, followed by Dyspnea and Tachypnea. Clamp the Catheter to Prevent more air from Embolizing into the venous circulation. Place the client in Trendelenburg position on the Left side, causing any existing air to rise and become trapped in the Right Atrium. Administer O2 if necessary to relieve dyspnea. Notify the HCP or call an RRT to provide further resuscitation measures. Stay with the client to provide reassurance and monitoring as the air trapped in the Right atrium is Slowly absorbed into the bloodstream over the course of a few hours. " Pulmonary Artery (PA) Catheter: When observed a spontaneously wedged waveform on the PA catheter monitor, the balloon port should be Deflated immediately and Locked to prevent accidental re-inflation. The Waveform indicates a "wedged" position of the catheter, meaning that the balloon may be Inflated or the catheter has Advanced too far into the PA, occluding that branch of the PA. PA Wedge Pressures are measured periodically to assess Left ventricular function or Left ventricular end diastolic pressure (Ventricular Preload). The balloon should be Inflated for only 10-15 seconds and then allowed to Deflate passively. A balloon that is Inflated for a Long Period may cause PA Rupture or Damage. Locking the balloon port of the PA catheter will prevent the balloon from being Accidentally Inflated. The Pressure Bag should be 300 mm Hg. 57 60 NCLEX RN STUDY GUIDE Lice- use the Shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb. Scleroderma: Overproduction of Collagen. No Cure. Tx: Control Symptoms. Prevent Further Complications. Sedation: Midazolam/Versed (Benzodiazepine): given for Conscious Sedation. Risk for Resp. Depression & Hypotension. Diazepam (Benzodiazepine): commonly used tranquilizer given to reduce Anxiety before surgery. Four Side-Rails Up: can be considered a form of restraint. Even in LTC facility when a client is a fall risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked. Seizure: Phenytoin: Drug Level 10-20. Should Not Stop abruptly. Stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing Ca2+ (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can Decr. absorption. Flushing the tube with 30-50 mL of water before and after. Can cause Liver damage. Monitoring of Liver function test. (Yellow of the skin) Can cause Gingival Hyperplasia, maintain Oral hygiene. Rash. Stop med. Oral contraceptives effectiveness is Decr., use alternative birth control methods. Teratogenicity. IV Phenytoin can cause Hypotension and Arrhythmias (Bradycardia) Phenytoin Toxicity: Nystagmus, Diplopia, Slurred Speech, Rash, Dizziness, Nausea, Ataxia (Gait Unsteadiness & Coordination), Lethargy, Coma. 60 61 NCLEX RN STUDY GUIDE Carbamazepine: Can be used for Trigeminal Neuralgia (CN V) for Neuropathic Pain. Associated w/ Agranulocytosis (Leukopenia). Risk for Infection. Don’t take with Grapefruits Valproic Acid: Seizure (epilepsy) and Bipolar med. Common Side effect: N/V, Hair loss, Tremors, Vertigo, Fatigue, Thrombocytopenia, Edema, Weight Gain, Acne. Rare Serious Adverse Effect: Hallucinations, HyperAmmonemia, Liver Failure, Encephalopathy. Levetiracetam: antiEpileptic. Sepsis: SIRS: (2 or more) Temp > 100.4 or < 96.8 HR > 90 RR > 20. pCO2 < 32 mmHg WBC > 12,000/mm3 or < 4,000/mm3, > 10% bands. Sepsis and Anaphylaxis (along with the obvious Hemorrhaging): Reduce Circulating Volume by way of Increased Capillary Permeability, which leads to Reduced Preload (volume in the Left Ventricle at the End of diastole). Silicosis: a long-term lung disease caused by Inhaling large amounts of Crystalline Silica Dust, usually over many years. Simple Silicosis: Exposed to Low Conc. of Silica. Usually Asymptotic. Abnormalities are often detected on X- ray. Acute Silicosis: Develops within few years after Exposure. S/S: Rapid Onset of Dyspnea, Cough and Weight Loss. X-ray Reveals a Ground-Glass Appearance. Accelerated Silicosis: Characterized by Rapidly Progressing Symptoms and X-ray Changes. Complicated Silicosis: Characterized by Severe Scarring and Fibrosis of lung tissue. 61 62 NCLEX RN STUDY GUIDE Status Epilepticus (Life Threatening): Most important assessment parameter, Level of Consciousness. Treatment of choice: Benzodiazepine (Lorazepam, Diazepam, Midazolam) Shock: BP Hypotension, Pulse Tachycardia, Resp Tachypnea. Bedrest with extremities Elevated 20o, knees Straight, head slightly/ Elevated (Modified Trendelenburg). Anaphylactic Shock: has an acute onset, and manifestations usually develop quickly (20-30 minutes). Caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs, foods, and venom. Results hypotension and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine); these can lead to cardiac and respiratory arrest. Tx: Maintain Airway & Breathing (High Flow O2). Elevate legs. Volume Resuscitation w/ IV Fluids. Albuterol. Antihistamine/ Diphenhydramine. Corticosteroids. Epinephrine: Always given in TB Syringe (IM). Norepinephrine: Vasopressor used to Increase Stroke Volume, Cardiac Output, and MAP. Titrating a norepinephrine infusion upward to maintain the MAP within normal limits (>65 mm Hg). Remember the action of Vasopressin because it sounds like “Press In”, or VasoConstriction. Hydroxyzine (Antihistamine): Use for itching or hives. Also used as a Sedative to treat Anxiety. Give to PreOp (Commonly). S/S: Dry Mouth. Basophils: release Histamine during an allergic response. Sickle Cell Crisis: Two Interventions to Prioritize: Fluids & Pain Relief & Folic Acid/ Blood Transfusion. Maintain Bed Rest. Do Not give Demerol. Hydroxyurea (chemotherapy drug): report GI symptoms immediately, could be Sign of Toxicity. Help to Prevent Formation of Sickle-Shaped RBC. 62 65 NCLEX RN STUDY GUIDE Dantrolene Sodium (Muscle Relaxant): for Spasticity, may take a Week or more to be effective. HypoThermia: Medical Emergency. Alterations in acid-base balance, coagulation values, and cardiac function may also occur; can lead to Cardiac and Respiratory Failure and Coma. Should anticipate a workup for Sepsis and various types of Shock. S/S: Core Temp (eg, rectal) < 95 F (35 C), Mental status changes, Shivering, and Impaired coordination. HyperThyroidism: Elevated T4, Low TSH level. Graves’ Disease: Accelerated physical and mental function; sensitivity to heat. Fine/soft hair. Exophthalmos. Elevated T4, and Low TSH (the pituitary gland will try to compensate for excess T3 and T4). Thyroid Storm: Trigger by Stress Event. Life-Threatening! S/S: Tachycardia, Fever, Cardia Dysrhythmia (A. Fib), n/v, Diarrhea, Altered Mental Status/Confusion, Seizure, and HTN (Thyrotoxicosis) PropulThioUracil/PTU and Methimazole- prevention of Thyroid Storm. Reduce Iodine. S/S: Agranulocytosis. Lugol’s Solution: To Decr. the Vascularity of the gland before thyroid surgery. Burning sensation in the mouth, and Brassy taste are Adverse Reactions. Need to Report to the Dr. Pain. Could cause Hyperthyroidism. Radioactive Iodine: Flush the substance out of the body with 3~4 L/day for 2 days. Flush the Toilet Twice after using for 2 days. Limit contact w/ patient to 30 minutes/day. No Pregnant visitors/nurses and no kids. HypoThyroidism: Diminished T4 Myxedema Coma: Slowed physical and mental function, sensitivity to cold, dry skin and hair. May report Somnolence (Decr. met rate, body is slow and sleepy). Levothyrosine/Synthroid: May take several weeks to take effect. Notify doctor of chest Take in the AM on Empty stomach. 65 66 NCLEX RN STUDY GUIDE No Antacids, Ca2+, Fe. Ok during Pregnancy. Insomnia is a side effect of Thyroid hormones. Increased met. rate, your body is Too busy to sleep. Post-Thyroidectomy: Low or Semi-Fowler's, Support head, neck and shoulders (prevent neck flexion/ hyperextension). Trach at Bedside. Assess for Edema and Swelling of the airway. Bleeding behind the neck. Risk injury in the Parathyroid Gland (Decr. Ca2+). S/S: tingling around mouth, fingers, toe; muscle twitch. Ca2+ Gluconate should be kept available to treat Hypocalcemia. Hyper-ParaThyroid: fatigue, muscle weakness, renal calculi, back and joint pain. Constipation. (Incr. Ca2+). Polyuria is common with the Hypercalcemia caused by Hyperparathyroidism. [Low Ca2+, High Phosphorus diet] Hypo-ParaThyroid: [CATS] – Convulsions, Arrhythmias, Tetany, spasms, stridor (Decr. Ca2+). Acute: Positive Chvostek’s & Trousseau’s sign. Chronic: Dry skin, Brittle nails/hair, Parkinsonian syndrome, Tooth enamel Hypoplasia. The Parathyroid Gland relies on the presence of vitamin D to work. [High Ca2+, Low Phosphorus diet] After Total Hip Replacement: don't Sleep on Operated side, don't Flex hip more than 45~60o, don't Elevate HOB more than 45o. Maintain hip Abduction by separating thighs with pillows. Don’t stay in same position for more than 1 hour. Buck's Traction (Skin traction/Knee immobility): Elevate foot of bed for counter-traction. 66 67 NCLEX RN STUDY GUIDE Back are q2hr (to prevent Pressure Sore). Trapeze to reduce friction and shear. Dorsiflex the affect foot to test for peroneal nerve (foot drop). Positioning boot to prevent Foot Drop. Place Apparatus First then place the weight when putting traction. No Weight on the Floor. Never release traction UNLESS you have an order from the MD to do so. Bryant’s Traction: Children <3yo, <35 lbs with Femur Fx. Dunlap Traction: Skeletal or Skin Russell Traction: Femur or Lower Leg Post-Transplant patient: Infection Control is Most important. Immunosuppressant therapy. Trendelenburg Position: may Increase Cerebral Edema Trendelenburg Test: To detect Gluteus Medius Tendon Tears or Weakness in the Hip Abductors. For Varicose Veins: If they Fill Proximally = Varicosity. Triage: In an emergency, patients with Greater chance to live are treated First Triage the person who is most likely to Not survive Last. Red (Immediate): Injuries are Life-Threatening but survivable with Minimal intervention. Ex: Hemothrax, Tension Pneumothorax, Unstable Chest and Abdominal Wounds, Incomplete Amputations, Open Fx's of Long Bones, Occluded Airway, Actively Bleeding. 2nd/3rd degree Burn w/ 15%-40% of total body surface. Yellow (Delayed): Injuries are Significant, Require Medical Care, but can Wait Hours w/o Threat to Life/Limb. Ex: Stable Abd Wounds w/o evidence of hemorrhage, Fx requiring open reduction, debridement, external fixation, most Eye and CNS injuries, Burns. 67 70 NCLEX RN STUDY GUIDE WBC: Basophil- Allergic Response (AB) Eosinophil- Parasitic Infestation (EP) Lymphocyte- Viral Infection (LV) Neutrophil- Bacterial Infection (BN) William's Position (Williams Lumbar Flexion Exercises): Semi-Fowlers with Knees Flexed (incr knee gatch) to Relieve Lower Back Pain. Wilm’s Tumor (Nephroblastoma): usually Encapsulated Above the Kidneys causing Flank Pain. Do Not Palpate Abdomen; could Disrupt the Tumor Cells (S/S: abdomen distention). Herbal Supplement Uses Side effects Ginkgo Biloba Memory enhancement Increased bleeding risk Ginseng Improved mental performance Increased bleeding risk Saw Palmetto Benign prostatic hyperplasia Mild stomach discomfort Increased bleeding risk Black Cohosh Postmenopausal symptoms (hot flashes & vaginal dryness) Hepatic injury 70 71 NCLEX RN STUDY GUIDE St John's Wort Depression Insomnia Drug interactions: Antidepressants (serotonin syndrome), OCs, anticoagulants (↓ INR), digoxin Hypertensive crisis Kava Anxiety Insomnia Severe liver damage Licorice Stomach ulcers Bronchitis/viral infections Hypertension Hypokalemia Echinacea Treatment & prevention of cold & flu Anaphylaxis (more likely in asthmatics) Glucosamin e Improve Joint Function Hypoglycemia may result when it is taken with Antidiabetic drugs Ephedra Treatment of cold & flu Weight loss & improved athletic performance Hypertension Arrhythmia/MI/sudden death Stroke Seizure MI = Myocardial Infarction; OCs = Oral Contraceptives. 71 72 NCLEX RN STUDY GUIDE 72 75 NCLEX RN STUDY GUIDE Posterior Fontanelle closes by 6 to 8 Weeks. Anterior closes by 18 Months. Glucose Tolerance Test: Result > 140 Needs further Evaluation. Pathological (nature) Jaundice: occurs Before 24hrs and last7 days. Physiological Jaundice: occurs After 24 hours. Magnesium Sulfate MgSO4 (Electrolyte): used to Stop Preterm Labor. Used to Prevent or Control Seizures in women with Preeclampsia or Eclampsia. Contraindicated: if Deep Tendon Reflexes are Ineffective. If patient Experiences Seizure During. Get the baby Out STAT (Emergency). Antidote: Ca2+ Gluconate Phenobarbital (Barbiturate): used to help you Sleep or may be used to help Control Seizures. For Coma Induction. “Barb Coma” Can be taken during Pregnancy Phenytoin (anticonvulsant) is Contraindicated. Pitocin: used for Uterine Stimulation. Placental should be in Upper part of Uterus. Placental Abruption (Emergency): Detachment/ Separation from the Uterus. Pain. but No Bleeding. Need to Monitor Volume Status (I&O). Placental Previa: Covers the Opening of the Cervix. No pain, there is Bleeding. If the baby is a Posterior Presentation, the Sounds are heard at the Sides. 75 76 NCLEX RN STUDY GUIDE If the baby is Anterior, the Sounds are heard closer to Midline, between the Umbilicus and Sides. If the baby is Breech, the Sounds are High up in the Fundus near the Umbilicus. If the baby is Vertex, they are a little bit Above the Symphysis Pubis. RhoGAM: given at 28 weeks & 72 hours Post Partum, IM. Only given to Rh Neg. Mother. Rh- mothers receive RhoGAM to Protect Next baby. Positive Indirect Coomb’s Test: Don’t Need to give RhoGAM bc she has antibody. Negative Coomb’s Test: Need to Give. Never get pregnant with a German Measles (Rubella). “bella” No MMR (Live Vaccine). Shoulder Dystocia: baby Cannot make it down to canal. " Nursing actions to Improve Fetal Perfusion and Oxygenation include: Discontinue Uterotonic Drugs (eg, oxytocin [Pitocin]) to Reduce Uterine Activity- First Action Change the Maternal Position to the Left side to Relieve Compression of the Inferior Vena Cava Administer Oxygen at 8-10 L/min via nonrebreather face mask Give prescribed intravenous (IV) bolus of Lactated Ringer's or Normal Saline 76 77 NCLEX RN STUDY GUIDE Notify the HCP Woman in Labor w/ Non-Reassuring FHR (Late Decels, Decreased Variability, Fetal Bradycardia): Turn On Left side (and give O2, stop Pitocin, Increase IV fluids). For Cord Compression, place the mother in the Trendelenburg Position because this Removes Pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity). Prolapsed Cord (Umbilical cord comes out of the Uterus): Knee-Chest position or Trendelenburg. Cover it with Sterile Saline Gauze to Prevent Drying of the cord and to Minimize Infection. If the Water Breaks and she is Any Minus Station, there is a Risk of Prolapsed Cord. For Late Decels, turn the mother to her Left side, to allow More Blood flow to the Placenta. For any kind of Bad Fetal Heart Rate Pattern, you give O2, often by mask. 77 80 NCLEX RN STUDY GUIDE Breast milk production is a supply-and-demand process. Expression of breast milk and stimulation of the breasts result in continued milk production and should be Avoid in clients who intend to exclusively formula feed. Feed Upright to Avoid Otitis Media. BronchoPulmonary Dysplasia (BPD): Dysplasia means Abnormality or Alteration. Risk: Mechanical Ventilation. Premature newborns with immature lungs are ventilated and over time it damages the lungs. Other Risk could be Infection, Pneumonia, or other conditions that cause Inflammation or Scarring. Candidiasis: White Patches that Cannot be Remove from baby’s Mouth. If you can, it is Formula. It is always the Correct answer to Report Suspected Cases of Child Abuse. Infant w/ Cleft Lip: position on Back or in infant Seat to prevent trauma to suture line. While feeding, hold in Upright position. Cryptorchidism: Undescended Testis Risk Factor for Testicular Cancer Later in life. Start teaching boys Testicular Self Exam around 12, because most cases occur During Adolescence. First Sign of Cystic Fibrosis may be Meconium Ileus at Birth. Baby is Inconsolable, Do Not Eat, Not Passing Meconium. Voiding Cystourethrography: Post: Drink a lot of fluids to flush the dye. 80 81 NCLEX RN STUDY GUIDE Intussusception: Common in kids with CF. Obstruction may Cause Fecal Emesis, Currant Jelly Like Stools (Blood and Mucus). URQ. Ileum telescopes into Cecum. Sausage shaped mass, Dance Sign (empty portion of LRQ). Abd pain. Stool mixed with Blood & Mucus “Jelly Currant”. Barium Enema: may be used to Hydrostatically Reduce the Telescoping. Resolution is Obvious, with Onset of Bowel Movements. Developmental: 2-3 months: turns Head Side to Side 4-5 months: Grasps, Switch & Roll 6-7 months: Sit at 6 and Waves bye-bye 8-9 months: Stands Straight at 8 10-11 months: Belly to Butt (phrase has 10 letters) 12-13 months: twelve and up, Drink from a Cup Birth Weight: Doubles by 6 month and Triple by 1 year of age. Head and Chest Circumference are Equal. Able to sit down from a standing position WithOut assistance. Lower Central Incisors usually between age 6-10 months. The following is a quick assessment formula to calculate the expected # of teeth during the first 24 months: 
 Age of child (in months) – 6 = Expected number of teeth 
 A 12-month-old should have approximately 6 teeth, and by age 30 months all primary teeth (20) should have erupted. 81 82 NCLEX RN STUDY GUIDE Stranger Anxiety is greatest 7 - 9 months. Separation Anxiety peaks in Toddlerhood: Protest, Despair, Detachment. Toddlers need to express Autonomy (Independence) If you gave a Toddler a Choice about taking medicine and he says No, you should leave the room and come back in five minutes, because to a toddler it is another episode. Next time, don’t ask. 4 Years- old kids Cannot interpret Time. Need to explain time in relationship to a known Common Event (eg: "Mom will be back after supper"). School-age kids (5 and up) are old enough, and should have an Explanation of what will happen a week before surgery such as tonsillectomy. An Ill child Regresses in Behaviors BSA is considered the Most Accurate Method for Medication dosing with kids Interpersonal model (Sullivan): Behavior motivated by need to Avoid Anxiety and Satisfy Needs 1. Infancy 0-18 months others will satisfy needs 2. Childhood >6yrs learn to delay need gratification 3. Juvenile 6-9 years learn to relate to peers 4. Preadolescence 9-12 yrs learns to relate to friends of opposite sex 5. Early adolescence12-14yrs:learn independence and how to relate to opposite sex 6. Late adolescence 14-21yrs: develop intimate relationship with person of opposite sex is this not about communication. 82 85 NCLEX RN STUDY GUIDE Heroin Withdrawal Neonate: Irritable Poor Sucking Hip Developmental Dysplasia (HDD): a set of Hip Abnormalities ranging from Mild dysplasia of the hip joint to Full dislocation of the Femoral Head. Barlow & Ortolani Maneuvers. S/S: < 2~3 months old, Presence of Extra Inguinal or Thigh Folds, Laxity of the hip joint on the Affected side. Disappear After 2~3 Months due to Development of Muscle Contractures. Pelvic Tilt w/ Lordosis if Not Corrected. Hirschsprung’s Disease (HD): Megacolon. Diagnosed with Rectal Biopsy looking for Absence of Ganglionic Cells. Cardinal Sign in Infants is Failure to Pass Meconium. Later the Classic Ribbon-Like and Foul Smelling Stools. Bile is Lower Obstruction. (Green Bilious Vomiting) No Bile is Upper Obstruction (Pylorus Stenosis) A Positive Western Blot in a child <18 months (presence of HIV Antibodies) indicates only that the mother is Infected. Two or more Positive p24 Antigen Tests will confirm HIV in kids <18 months. The p24 can be used at Any Age. PCR: in Infants. After a Hydrocele Repair provide Ice Bags and Scrotal Support. Impetigo: Not contagious after 24 hours of antibiotics. IntraOsseous Infusion: Pediatric life-threatening Emergencies. Temporary, life-saving measure. D/C after Venous Access is Obtained. When IV Access cannot be obtained, an Osseous (Bone) Needle is hand-drilled into a bone (usually the Tibia), where Crystalloids, Colloids, Blood products and drugs can be administered into the Marrow. 85 86 NCLEX RN STUDY GUIDE Isoproterenol (a beta agonist): Cannot be administered by Intraosseous infusion. Kawasaki Disease: causes Inflammation of Arterial walls (Basculitis). Coronary arteries are affected, can lead to scarring of the Coronary Arteries or development of Coronary Aneurysms. Not Contagious. Acute - Sudden onset of High fever (report fever > 5 days) that does Not respond to Antibiotics or Antipyretics. The child becomes very Irritable (can last up to 2 months) and develops swollen red feet and hands. The lips become painfully swollen and cracked, and the tongue can also become Red (Strawberry Tongue) Given soft foods and clear liquids. Non-stimulating, quiet environment will help to promote rest. Follow-up appointments for Cardiac evaluation are important. Subacute - Skin begins to Peel from the hands and feet. The child remains very irritable. Skin discomfort can be eased with Cool compresses and Lotions. No treatment is needed, but the new skin might be very tender. Convalescent - symptoms disappear Slowly. The child's temperament returns to normal. Systemic Vasculitis: Irritablity, Knee Pain, Skin Peeling. Tx: IV Gamma Globulin (IVIG) and AcetylSalicylic Acid (ASA) to prevent Coronary Artery Aneurysms. IVIG (IV Immunglobulin) creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large quantities. Monitored for symptoms of Heart Failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing). No Live Vaccine 11 months after receiving IVIG. AcetylSalicylic Acid (ASA) can cause Reye’s syndrome (Encephalopathy- Swelling of the Liver and Brain), when given to Children. Lead Poisoning Test: around 12 months of age. Anemia with Milk-aholics: Too much Milk Reduces Intake of other Essential Nutrients, Especially Iron. Mother should Not put anything But Water in that kid’s bottle 86 87 NCLEX RN STUDY GUIDE During naps/over-night. Juice or milk will Rotten that kids Teeth right out of his head. Watch out for questions suggesting a child drinks More than 3-4 cups of milk each day. It is essential to Maintain Nasal Patency with children < 1 yr. because they are Obligatory Nasal Breathers. Neonatal Abstinence Syndrome: Autonomic Nervous System Symptoms: stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and tachypnea. Tx: swaddling and keeping nasal passages clear. Central Nervous System Symptoms: irritability, restlessness, high-pitched crying, abnormal sleep pattern, and hypertonicity/hyperactive primitive reflexes. Tx: medication and protecting the skin. Gastrointestinal symptoms – poor feeding, vomiting, and diarrhea. Tx: small, frequent feedings With Omphalocele (Sealed by Peritoneal Layer) and Gastroschisis (No Peritoneal Layer): (Herniation of Abdominal Contents) Dress with Loose Saline Dressing covered with Plastic Wrap, and keep eye on Temp. Kid can Lose Heat quickly. Parvovirus B19 (Contagious): Fifth disease causes a distinctive red rash on the face that makes a child appear to have a "slapped cheek.". Pertussis (Whooping Cough): Highly Contagious Respiratory disease and requires Droplet Precautions. Can be Deadly if contracted in infancy Before Vaccination is started. This client should be placed in Isolation Immediately to Prevent the spread of disease. S/S: Paroxysms of Rapid Coughing that lead to Vomiting (can Last up to 6 weeks) Tx: can be Prevent w/ DTaP. If pt already have Pertussis, treat with Abx Therapy. 87 90 NCLEX RN STUDY GUIDE Treated with Ibuprofen or Acetaminophen. Do Not require Anti-Seizure Medications. HypoSpadias: Abnormality in which Urethral Meatus is located on the Ventral (Back) surface of the penis anywhere from the Corona to the Perineum (Hypo means Low (for Lower side or Under side)) EpiSpadias: Opening of the Urethra on the Dorsal (Front) surface of the penis. SIDS (Sudden Infant Death Syndrome): Lay the kid on his Back (Back To Sleep). Infant w/ Spina Bifida: position Prone, so that Sac does Not Rupture. Incr. the Risk while taking Valproic Acid During Pregnancy. Esophageal atresia (EA) /Tracheoesophageal Fistula (TEF): consist of a variety of Congenital Malformations that occur when the Esophagus and Trachea do Not properly Separate or Develop (Surgical Emergency). S/S: Frothy Saliva, Coughing, Choking, and Drooling. Apnea and Cyanosis During feeding. Tx: NPO, Supine, HOB 30o, Suction Equipment. Risk for Aspiration: NPO Until Surgery. Ninety Ninety Traction: used in a School-Age kid with Femur or Tibial Fracture with Extensive Skin Damage. The name refers to the Angles of the Joints. A pin is placed in the Distal part of the Broken bone, and the Lower Extremity is in a Boot Cast. The rest is the Normal Pulleys and Ropes (Visualizing with Balanced Suspension). Bryant’s Traction: used for Femurs and Congenial Hip for young kids. (children <3yo, <35 lbs) Hips should Clear the Bed. Vaccinations: 90 91 NCLEX RN STUDY GUIDE MMR vaccine is given SQ not IM. MMR and Varicella immunizations come Later (15 months). Anaphylactic Reaction to Baker's Yeast is Contraindication for Hep B vaccine. Ask for Anaphylactic Reaction to Eggs or Neomycin before MMR Check Egg Allergy Before Flu shot. Age 4 to 5 yrs child needs DPT/MMR/OPV. If kid has Cold, Can still give immunizations HIV Kids Avoid OPV and Varicella vaccinations (Live), But give Pneumococcal and Influenza. MMR is Avoided only if the kid is Severely Immunocompromised. Parents should wear gloves for care, not kiss kids on the mouth, and not share eating utensils. Vastus Lateralis: is IM administration site for 6 month infants VentroGluteal: For toddlers Above 18 months The Deltoid and Gluteus Maximus are appropriate sites for Children Warm a Newborn: Skin to Skin Contact covered with a blanket on mom. NCLEX TIPS An answer that Delays care or treatment is ALWAYS wrong If two of the answers are the exact Opposite, like bradycardia or tachycardia... One is probably the answer. If two or three answers are Similar or are Alike, None is Correct. When asking patients’ questions NEVER use “why” questions. Eliminate all “why?” answer options. If you have never heard of it… please don’t pick it! Always Deal with Actual problems or harm Before Potential problems. Always select a “Patient Focused” answer. An answer option that states "reassess in 15 minutes" is probably Wrong. Small Frequent feedings are Better than Larger ones. 91 92 NCLEX RN STUDY GUIDE If the patient is Not a child an answer with family option can be Ruled Out easily. To access Role Relationship pattern Focus on Image and Relationships With Others. When getting down to Two answers, Choose the Assessment answer (Assess, Collect, Auscultate, Monitor, Palpate) Over the Intervention Except in an Emergency or Distress situation. Read the hell of the question 2-3 times without looking the answers 
 Read the sentences Completely 
 Keep your 1st choice (don’t change it unless you know is wrong) 
 Stick with what you know (no what if) 
 If you don’t know the Adverse Effects of a drug- Choose the Worst or something related to Kidney, Liver, Immunosuppression. If the question is reviewing Prescriptions, Look for Answers with Liver disease (Hepatitis) or Kidney diseases (Nepho-). Many drugs are Metabolized by them. Do not use Why or I understand statement when Dealing with Patients 
 Answer the question to the Pt even if one of the options is a fact 
 If option of Restraints, Don’t pick (Nclex lady doesn’t like it) 
 Assume the Worse, what’s going to Kill the patient (faster) in priority 
 When receiving nurse from Different unit, give her General Nursing need pt (Nothing rt w/ the specialty unit) 
 When accommodating pt choose similar dx, age for kids 
 If you have a smoke secession pick it or risk factor Choose smoking 
 Therapeutic response: focus on pt feelings, gather more info 
 Don’t hold Oxygen for the death 
 Don’t Pass the buck to another person 
 Do Something Before calling the Dr 
 Avoid: All, Always, None, Never. 
 SATA: stick with what you know (if you never heard of it, no one did) 
 When you don’t know the answer: Assume the Worst (no happy questions) 
 If you don’t know the dx or patho: choose the options with a Complication or things that we should not do 
 Don’t ever Change doses or Advise patient. 
 Be the Nice nurse 
 If it sound Right to you- go for it 
 When giving meds: check time, labs, s/s try to look what is wrong Take your time, read the question & answer before submitting it 92